rkindlund
Networker
Based on this op report (it is a male) I am inclined to go with 21555 but can also see 19120. Path report came back as a lipoma. What would you code?
Name of Procedure:
Excisional breast mass.
Preoperative Diagnosis:
Left breast mass and right breast mass.
Description of Procedure:
Patient brought to the operating room, prepped and draped in standard sterile fashion. He was given 2 g of IV Ancef on induction of anesthesia. I began on the left breast mass. I made a skin incision after injection 0.25% Marcaine with epinephrine. I went down onto the soft tissue mass. This was easily delivered off the field and will be sent for permanent in formalin. This looked very much like a lipoma and the patient has a history of multiple lipomas. I then turned my attention to the right breast mass. In like manner, I injected local anesthetic, used a 15-blade scalpel to open the skin, dissected down. The soft tissue mass was easily delivered. I used electrocautery for hemostasis and the wounds were closed with
3-0 Vicryl in the dermis and 4-0 Monocryl in subcuticular fashion. Patient tolerated procedure well.
Name of Procedure:
Excisional breast mass.
Preoperative Diagnosis:
Left breast mass and right breast mass.
Description of Procedure:
Patient brought to the operating room, prepped and draped in standard sterile fashion. He was given 2 g of IV Ancef on induction of anesthesia. I began on the left breast mass. I made a skin incision after injection 0.25% Marcaine with epinephrine. I went down onto the soft tissue mass. This was easily delivered off the field and will be sent for permanent in formalin. This looked very much like a lipoma and the patient has a history of multiple lipomas. I then turned my attention to the right breast mass. In like manner, I injected local anesthetic, used a 15-blade scalpel to open the skin, dissected down. The soft tissue mass was easily delivered. I used electrocautery for hemostasis and the wounds were closed with
3-0 Vicryl in the dermis and 4-0 Monocryl in subcuticular fashion. Patient tolerated procedure well.